The traditional approach to treatment of dental caries has been complete removal and subsequent restoration.  During the past decade this approach has been challenged, based on a greater understanding of the disease process.  The focus being on adequate restorations rather than a complete excavation of caries, with particular benefits for the treatment of deep caries.

Two options are currently used, a two-step (or “stepwise”) approach with, carious dentine being incompletely removed at the first step and left under a temporary dressing. In a second visit some months later, a re-entry procedure is performed, and complete removal of all carious tissue and a definitive restoration are provided.  In the one step approach caries is partially removed and residual caries is sealed under a definitive restoration in the first and only visit. The aim of this review was to critically summarize and evaluate results of randomized controlled trials (RCTs) for both deciduous and permanent teeth, comparing complete and incomplete caries removal techniques.

The Cochrane Central Register of Controlled Trials (CENTRAL), Medline, PubMed Embase and Clinical Trials.gov databases were searched for randomised and quazi-randomised trials.  Only those in English and German were considered.  Risk of bias was assessed using Cochrane guidelines.  The outcomes considered were pulpal exposure during treatment; post-operative pulpal symptoms, and failure e.g., restorations lost or to be replaced, pulpitis, non-restorable teeth). Meta-analysis was conducted with a random effects model and GRADE methodology was used to rate quality.

• Ten studies were included (1,257 patients; 1,628 teeth). The majority of studies involved children with just two involving adults.  Most studies had considerable risk of bias.
• There was a significant overall risk reduction for pulpal exposure (OR; 0.31, 95% CI [0.19-0.49]) for incomplete excavation compared with complete caries removal.
• One-step incomplete caries removal indicated an even lower risk for this technique (OR; 0.20, 95% CI [0.06-0.61])
• There was a significant overall risk reduction of pulpal complications after incomplete compared with complete excavation (OR; 0.58, 95%CI [0.31-1.10]).
• Risk of failure was similar for incompletely and completely excavated teeth (OR; 0.97, 95%CI [0.64-1.46]).

The authors concluded

Based on reviewed studies, incomplete caries removal seems advantageous compared with complete excavation, especially in proximity to the pulp. However, evidence levels are currently insufficient for definitive conclusions because of high risk of bias within studies.

Comment

There have been a number of reviews of this topic since the 2006 Cochrane review by Ricketts et al and these are all noted in the discussion section of this review.

Links

F. Schwendicke, C.E. Dörfer and S. Paris
.  Incomplete Caries Removal: A Systematic Review and Meta-analysis.  J DENT RES published online 8 February 2013 DOI: 10.1177/0022034513477425

Ricketts D, Kidd E, Innes NPT, Clarkson JE. Complete or ultraconservative removal of decayed tissue in unfilled teeth. Cochrane Database of Systematic Reviews 2006, Issue 3. Art. No.: CD003808. DOI: 10.1002/14651858.CD003808.pub2.

Thompson V, Craig RG, Curro FA, Green WS, Ship JA. Treatment of deep carious lesions by complete excavation or partial removal: a critical review. J Am Dent Assoc. 2008 Jun;139(6):705-12. Review. PubMed PMID: 18519994; PubMed Central PMCID: PMC2692285

Hayashi M, Fujitani M, Yamaki C, Momoi Y. Ways of enhancing pulp preservation  by stepwise excavation–a systematic review. J Dent. 2011 Feb;39(2):95-107. doi:  10.1016/j.jdent.2010.10.012. Epub 2010 Dec 3. Review. PubMed PMID: 20971154.